BALTIMORE (WJZ) — A report released Friday by the University of Maryland Medical System’s board of directors in the wake of the “Healthy Holly” scandal found “significant aspects” of the board’s oversight and decision-making responsibilities were “deeply compromised” by both some board members and structural flaws in the board’s operation.

The report was the work of a special committee that was established in September. All five committee members were among the 11 new appointees to the board after the scandal broke.

It found some self-interested board members were able to take advantage of the system and its “ineffective” and “incomplete” conflict of interest policies.

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“The Special Committee did not identify many clear violations of UMMS policies; in the majority of cases, the COI transactions technically complied with the policies in force until 2019. But those policies allowed conflicted transactions to proceed and multiply, without careful or objective review, approval, or oversight of such transactions by the Board,” the report reads.

The report also found that former Mayor Catherine Pugh originally pitched the board’s purchase and donation of her self-published “Healthy Holly” books as a way to “support UMMS’s “population health” initiative by disseminating health-oriented educational materials to children.” Despite that, the report said there was no evidence that any executives ever actually read the first through fourth installments in the series.

It also includes a number of recommendations about governing practices, process improvements and other corrective actions, the system said. Among the recommendations are shrinking the number of board members, which would require a change to state law, more strictly implementing term limits and requiring annual board approval for conflict of interest transactions.

“There is no question the past conduct undertaken by certain former corporate officers and board members was extremely problematic and damaged the reputation of the System. This investigation was executed to ensure full accountability and transparency as the System moves forward from the troubling events that were discovered earlier this year,” officials said in a news release.

Despite the wrongdoing by some former leaders, officials said the “overwhelming majority of the Board and senior leaders worked diligently every day to serve our mission.”

In May, the system unanimously adopted a new conflict of interest policy which included detailed disclosure procedures for board members and requirements for when board members must recuse themselves from decision-making activities.

Under policy rules approved in May, the board cannot use sole-source procurement to award contracts or provide preference to a board member, a board member’s family member or a business with connections to the board member or a family member.

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